Identity and the
Foundational
Myth

This sample chapter is taken from Identity and the Foundational Myth: Psychoanalytic Insights into Gender Distress, in which Marcus Evans explores the psychological processes that may underlie gender distress and the implications for clinical practice.

Aspects of Psychoanalytic Assessment and Treatment of Gender-Dysphoric Young People outlines a psychoanalytic approach to assessment developed through many years of clinical work with adolescents and young adults. Rather than beginning with assumptions about diagnosis or treatment, the emphasis is on understanding the individual's developmental history, family relationships, emotional life, unconscious conflicts and capacity for symbolic thought.

The chapter argues that assessment is not simply a process of gathering information or determining eligibility for treatment. It is the beginning of a therapeutic endeavour that helps individuals develop a deeper understanding of themselves and supports thoughtful, informed decision-making. The emphasis throughout is on curiosity, careful exploration and maintaining a reflective space in which complex psychological realities can emerge.

Although written from a psychoanalytic perspective, the chapter will be of interest to psychiatrists, psychologists, psychotherapists, nurses, social workers and other mental health professionals involved in the assessment and treatment of young people experiencing gender distress.

Chapter 4. Aspects of psychoanalytic assessment and treatment of gender dysphoric young people

The many everyday developmental struggles among trans-identified and gender-dysphoric young people which I have observed appear to have resulted in the presence of many similar concerns and issues during psychotherapy.

This chapter discusses some general aspects I have observed during psychotherapy of similar developmental struggles, concerns, and issues among trans-identified and gender-dysphoric young people. The chapters following this one provide illustrative composite case histories.

One important issue to discuss is the approach undertaken in clinical interactions. The psychiatric approach is designed to ascertain the patient’s mental state, diagnosis, degree of illness, and risk; the clinician actively assesses the patient’s presentation. The psychoanalytic approach is oriented around a receptive approach, following the patient and their preoccupations. While I always aim to understand the individual’s presentation regarding their development, I am also interested in exploring the unconscious forces that may be influencing the individual’s perceptions and belief system. A psychoanalytic assessment and therapy can help evaluate an individual’s unconscious conflicts, anxieties, impulses, and defences. The psychotherapeutic task is to explore and observe the nature of the patient’s inner world, including their illusions and the challenging nature of their relationship with their emerging adult self. It aims to provide a holistic picture of how various aspects of an individual’s personality and history interact by thoroughly exploring these, as well as childhood history, family, ego strength, capacity for symbolic thought, and risk factors. In a psychoanalytic evaluation, the process is led by the patients and the material they choose to bring. The relationship with the analyst can allow the exploration of all sorts of conflicts and anxieties that may have been difficult to explore in other contexts. In this way, the transference relationship can be used to examine unconscious preconceptions, including those about the individual in relation to parental figures.

Depending on the clinical setting and situation, an active and receptive psychoanalytic approach can be necessary. In many cases, clinicians move between being active and receptive, depending on the aim of the clinical encounter. The practitioner needs to assess the individual’s ability to adopt a psychoanalytic approach. Although psychoanalysis may benefit some patients experiencing gender confusion, in my experience, predicting which patients will benefit is impossible, as defences may soften over time because of the therapeutic process. Even for those not suited for psychotherapy, thinking about the meaning of the patient’s presentation can help clinicians tune in to their patient’s preoccupations.

I start by asking the patient what is on their mind and then about one or two aspects of their history as part of the assessment process. I do this to look for clues regarding the individual’s psychological structure and relationship with early objects. I follow the material in subsequent sessions to tune in to the person’s unconscious conflicts and anxieties. When working this way, it is not my role to force the patient into a particular way of thinking. Instead, I try to understand their psychological structure while thinking about how patterns of relating are repeated in the therapy. The patient may be unaware of the unconscious factors influencing his thinking and decision making. A period of trial therapy can often help patients begin taking an interest in the functioning of their minds. One needs to be sensitive to individuals’ resistance to the exploratory process while trying to interest them in this process of exploration. This is part of good preparatory work and helpful for informing decisions regarding transition. When a person states he or she is trans or complains of gender dysphoria, it is essential to listen and explore what is occurring for the individual. The presentation and message from patients can be very fixed and one-dimensional. Rather than presenting a distressing psychological symptom—feelings of detachment from the body they were born in that are felt to contain unwanted aspects of the self, for instance—patients might act as if they are a customer who has been sold the wrong suit and is outraged at the reluctance of the shop to give them a new one. In this way, a complex mental configuration is treated as a concrete problem in the body.

I have seen many individuals present with the belief that transition can resolve their internal conflict and help them claim their bodies and minds for themselves. Some individuals looking to establish a distance between themselves and their natal sex find social transition suffices, while others believe powerful medical and surgical interventions must accompany the social transition. Their desire for a physical solution can override the need for thoughtful evaluation of the gains and losses or risks involved in the transition. As discussed in earlier chapters, I see the idea of transition in some individuals as a retreat from developmental demands involved in transitioning from childhood to adulthood, and have been referring to the concept of a psychic retreat, developed by Steiner (1993). The term refers to a system of defences designed to protect the ego from fears of fragmentation on the one hand and anxieties associated with integration on the other. The psychic retreat provides a resting place from the demands of development, where psychological stability is achieved at the expense of development and change. Although psychic retreats provide an important defensive structure that can protect the ego from depressive collapse, this defensive structure comes at a price. Psychic retreats prevent the sort of reality testing that accompanies development.

Nonetheless, some individuals spend their lives in some form of psychic retreat, as life outside is unmanageable, accepting the restrictions imposed by the retreat as the price they pay for the solution to their distress. Individuals seeking a psychic retreat need help and support in coming to terms with and accepting who they are, including perceived faults, limitations, and (if they possibly can) their natal sex, as part of the maturational process. Difficulties with the primary object and separation, often present, mean that the patients also need support going through the process of mourning. Individuals who have become entrenched in a psychic retreat will likely need long-term psychotherapeutic treatment.

The therapeutic process itself is a challenge

Therapy aims to help patients see how their internal structure, conflicts, and identifications influence their thinking and ways of relating to themselves and others. Treatment is complex, as patients who are trans-identified or have gender dysphoria often have difficulty thinking about themselves and reflecting on their mental functioning. The earlier chapters discussed how some individuals have been unable to internalise a good internal object or lacked a third object to support their need to reflect on themselves and their objects. They also described how an individual with a fragile ego often relies on or resorts to primitive mechanisms, such as denial, splitting, and projection, to reduce anxieties and conflicts between different aspects of the psyche. However, denial, splitting, and projection also interfere with the capacity for symbolic thought, which is necessary for psyche reflection, including as part of the therapeutic process. Britton described the difficulty for some of reflecting upon themselves or having others reflect upon them:

The familiar split configuration of the positive oedipal configuration, which is usually used to separate love and hate, in these cases is used to provide a structure to segregate desire for subjective understanding and love from the wish for objective knowledge and a shared intellectual identity. (Britton, 2004, pp. 50–51)

In analysis, he noted two possibilities that sometimes occur:

Instead of there being two connected, independent minds, there are either two separate people unable to connect or two people with only one mind. These two situations could not be more different from each other in analysis. They have in common their inability to function ordinarily and their terror of integrating separate minds. (Ibid., p. 52)

In addition, many of those who are trans-identified or gender dysphoric harbour grievances, and one of the most significant restrictions of a psyche governed by grievance is a limited capacity for thinking. As discussed earlier, the fixed nature of the belief in the trans identity can act as an external shield from the threatening nature of the internal world. It also acts as a protective exoskeleton against other anxieties regarding the functioning of the individual’s mind and the lack of capacity for symbolic thought and self-reflection. The fixed yet unexamined belief held by many that medical transition will cure their difficulties means the trans identity functions like an overvalued belief system used to deny and triumph over painful realities. Individuals under pressure may invest in overvalued belief systems. Such systems avoid the painful process of reality testing and function like psychic islands. They remain insulated from the effects of the confrontation with external reality and are often believed to offer concrete solutions to painful psychic conflicts, acting as psychological support that protects the ego from fragmentation.

Patients may feel these beliefs, which provide psychological stability, need to be protected from this sort of examination, even if their tendency to fly in the face of reality can cause damage. They may feel that they lack an ego structure that can help them bear the psychological pain of self-reflection. It can be challenging and threatening for these patients to think about the cause of the self-hatred emanating from the mind. Indeed, unwanted elements of the psyche that have been denied, split off, and projected may be experienced as threatening the equilibrium of the ego if returned to the individual. Thus, the mind and the capacity to think about emotions are often treated as a threat that needs to be suppressed, shut out, and avoided. Thought and dialogue expose the individual to turbulent psychological movement and change, the natural enemies of a mind seeking psychological control and equilibrium at all costs.

In addition, in their unmanageable struggle to integrate subjective and objective experiences, patients often retreat to an area of their minds where they employ logic as a way of managing and controlling psychic pain. This “black and white” thinking aligns with “if only” daydreams, and certainty and conviction in the belief system replace doubt, ambivalence, and confusion. They may withdraw from the body—with all of its desires, experiences, and needs—into the mind, which acts as a “mission control”. It watches and controls the individual and any others they encounter. As they have adopted detached control in preference to the anxieties and pleasures associated with being alive, the patient’s or analyst’s curiosity and feelings can be seen as the enemy in this psychic arrangement.

Consequently, thinking about themselves in a free and imaginative way is often experienced by trans individuals as dangerous, as it involves questioning rigid beliefs and ways of thinking that are being held onto persistently and consistently to provide psychological stability. Bell (2020) describes a state of mind where the wish to think over time and to understand why a particular child has developed gender dysphoria comes to be seen as an expression of “transphobia”. This creates a paranoid universe, a world in which “you are either for me or against me”, leaving no room for a mind that wants to think about things. They struggle to engage in free association and may experience an invitation to talk and think about themselves as a threat.

Sometimes, the patients’ capacity for symbolic thought tends to break down under emotional pressure. They may struggle to establish and maintain symbolic functioning in some regions of experience, as they commonly rely upon massive projective identification of unwanted aspects of the self into the rejected body (the rejected body is experienced as an obstacle to living the life they want). Thus, some individuals who identify as trans are terrified of their minds, believing they contain dangerous and potentially damaging unconscious phantasies and ideas. Due to the concrete nature of their belief system thoughts and words are often treated as if they could cause damage and lead to harm or violent conflict. Thoughts and words are also often experienced as menacing and confused with threatening and harmful physical actions because of the omnipotence of the individual’s thinking. For instance, “dead naming” refers to using an individual’s former name before transitioning. The name itself is experienced as an attack on the individual’s new life, like a ghost that returns to haunt the living. Thus, words and thoughts are not seen as vehicles of symbolic communication, benign or useful mental representations, states, or processes. Rather, they are weapons.

The restrictions in these individuals’ capacity to think, verbalise, control their minds, and engage with the analyst can result in a paucity of free-associative material, thereby depriving the analyst of the necessary insights to understand the patient. Instead, the curiosity and interest one might expect from the patient may have to reside in the analyst in the first instance.

Psychoanalytic work requires the analyst to adapt theory to the experience rather than the other way around. As part of the assessment process, I develop a hypothesis about the individual’s foundational myth—specifically their oedipal configuration and their role within the family. This initial framework can help to contextualise the transference and countertransference dynamics that emerge within the therapeutic relationship over time. I then refine and modify my understanding of the foundational myth as further elements unfold through the transference relationship.

The ever-present option of medical intervention (or additional medical intervention for some patients) further complicates the therapeutic process. Plans to transition medically can increase the individual’s sense of omnipotence and give rise to excitement as they believe they will triumph over both their parents and reality. For instance, for females,

It might be thought that giving up omnipotence and accepting receptive femininity would yield its own rewards, but such benefits tend to be delayed and uncertain. By contrast, omnipotence works instantly and with a magical certainty and often seems to have such a hold on the personality that its relinquishment is problematic. (Steiner, 2020, p. 81)

The use of omnipotent defences, bolstered by the promise of what medical interventions can deliver, is a potent and seductive psychological cocktail that makes the work of psychological exploration difficult and sometimes impossible. In a paper entitled “Trans-itory identities: Some reflections on gender identities”, Lemma states:

My aim is to explore what can appear to be, in some of the cases where medical intervention is sought, a premature embracement of the empowering potential of the transgender identification. This state of mind can undermine the painful psychic work required to establish what transgender means to the young person - an understanding is critical to post-operative adaptation if they are intent on body modifications to reduce the felt incongruence within the given body. (2018, p. 1091)

Compared to the promised power implicit in the concrete physical solution, psychotherapy involves pointing out the difference between omnipotent thinking, which promises dramatic magical solutions, and reality-based thinking, which limits omnipotence. This sort of insight involves a significant loss, as the individual’s development depends on the capacity to acknowledge their reliance on omnipotent modes of thought—forms that attempt to alter or deny reality, often at great psychological cost (Steiner, 2015). Psychological change depends on the individuals’ ability to acknowledge their attachment to omnipotent forms of thinking and the excitement accompanying the capacity to deny reality. However, the therapy process will inevitably lead to disappointment relative to their expectations based upon rigid beliefs, as talking about their difficulties may increase awareness. Still, it will not lead to a magical solution. The limiting of omnipotence does not only involve the loss of a magical solution; it is also often problematic for individuals to give up manic defences against psychic pain as they fear being overwhelmed by guilt about damage done in reality or phantasy.

Patient responses to the analyst and the process of psychotherapy

In a consumer-driven world, the notion that individuals can shape their identity at will—through external modifications rather than internal reflection—is deeply embedded in contemporary culture. Bell (2020) suggests that the commodification of identity fosters an illusion of instantaneous transformation, leading individuals to expect that merely changing their external appearance will resolve internal conflicts. This idea is particularly relevant in cases where the distress of gender dysphoria is connected to broader struggles with self-worth. If identity is viewed as something to be “purchased” through medical or cosmetic interventions, the developmental task of integrating various aspects of the self is overlooked. This is a crucial consideration in therapy, as patients may require assistance in distinguishing between the desire for external validation and the need for internal psychic work.

Some individuals agree to see an analyst to reassure their parents that a thorough exploration has occurred. This is something to which they may agree on a superficial level, but which may make them feel threatened if their defences are undermined by exploring the reasons for their wish to transition. The very fact the analyst wants to think about them feels like a threat to their state of mind that needs to be resisted and fought. In his paper “First, do no harm”, Bell (ibid.) describes how these patients can see thinking as an enemy to be destroyed. Some may feel that the analyst is deliberately undermining their freedom to choose their gender by forcing them to think about their doubts, conflicts, and confusions. An analyst’s questions about the basis or nature of the individual’s (deeply invested-in) belief system can be experienced as hostile threats to the psychological status quo. The clinician’s exploration approach may be felt to intrude and interfere with the patient’s psychological equilibrium by introducing doubt and uncertainty and thus anxiety. Some may believe that the analyst wishes, with reckless enthusiasm, to provide them with dangerous insights. A sense of threat may also arise from the curiosity of the analyst, tied to the patient’s perception of the analyst as a narcissist. The patient may view the analyst as someone who is not interested in the patient’s experience but only wants to be admired.

Patients often have a wish to control the therapeutic encounter by restricting access to thoughts which are experienced as potentially dangerous. However, at a conscious level, they often present themselves as confident. Joseph (1975) describes how some patients who are withdrawn project a desire for contact with the analyst while simultaneously withdrawing into a world of their own. They are unaware of the real nature of their internal structure and psychological relationships: perverse parts of the self, their pathological internal organisation, keep dependent parts and healthy parts of the self away from the analyst (Steiner, 1985). Rosenfeld (1971) described the relationship between pathological organisation and its promise of protecting the psyche from psychic pain in exchange for loyalty to a narcissistic system. Relevant for some patients is the “identificate” described by Sohn (1985), a shallow attachment to a chameleon-like identity based on bland arrogance, confusion, falseness, and corruption of psychic reality. More generally, the patient can worry that the fraudulent identification sought via transition cannot stand up to scrutiny and exploration. As described by Steiner (2011a, p. 18): “Emerging from a psychic retreat leads to the feeling of being observed. This leads to shame and humiliation, particularly if narcissistic defences have created an illusion or delusion of superiority.” Any attempt by the analyst to explore the wish to transition can thus also be experienced as a cruel form of control.

Patients who communicate threatening aspects of their inner world to the analyst may feel intruded upon when the analyst tries to give insight to the patient about the nature of the projections (Steiner, 1993). These interactions can lead to patients withdrawing back into a defensive position. They fear that the analyst wants to force some unwanted aspect of reality into them or get them to submit to a harsh version of reality that fails to understand their position. When a patient feels threatened, it can provoke a drive towards actions to foreclose exploratory therapy on the patient’s part and a wish to force the patient to pause for thought on the analyst’s.

The patient’s lack of curiosity may prompt the analyst to ask questions due to frustration or to avoid persecutory anxieties about the process. This frustration can drive the analyst into overactivity in asking questions or jumping to conclusions about the material rather than following the patient. The patient may then feel that they are not living up to the analyst’s expectations of an “ideal” patient who can freely express his thoughts and feelings. In this way, the sense of being the difficult child, and not the ideal child in their parents’ minds (as discussed in Chapter Two), can be repeated in therapy. The patient’s aggression towards the analyst for perceived failures in understanding may repeat early transferential experiences of feeling like a demanding or unappreciated child. In such moments, the patient moves towards a conviction that the full force of their contempt and hatred could destroy the therapeutic relationship entirely.

Another complicated situation may occur when the analyst attempts to draw attention to the patient’s lack of curiosity or how the patient projects doubt onto others, leading to an enactment of an internal conflict in the external world. In a similar way to exploration, these attempts can be experienced as the analyst attempting to undermine the individual’s solution. The patient may implicitly convey to the analyst that the analyst’s wish to think about the patient’s difficulties is an upsetting process which undermines the patient’s way of thinking about themself.

Frequently occurring complex situations

One needs to understand the belief system’s role in the individual’s mind and how it relates to the individual. The analyst also needs to consider the different levels of functioning within the patient. Focusing on forms of thinking and defence mechanisms can help clinicians find ways of working with individuals who may be highly defensive and concrete in their thinking and feel threatened by the functioning of their minds. What can sometimes be analysed in therapy is the idea that separation from the ideal object or self can only occur if there is concrete and physical separation from the primary object.

Similarly, the self-sufficient system against all attachments, including attachment to the body and the desires and impulses located in the body, can also be analysed to comment on the fear of life and the desires for life. Many patients are conscious of how their stance leaves them isolated and detached from any desire for life. Joseph (1975) describes a group of patients who are difficult to reach because they withdraw from being involved in life to the point that they mock the desire to engage in it. They bring to mind the observations of Rosenfeld (1971) and Joseph (1981), about a group of patients who develop defensive structures based on contempt for life. Some give the impression of watching life from their bedroom (for instance, the young people who live online, mentioned at the end of Chapter Three) where they retreat into a disembodied imaginary world. From the superior place in their mind, they look down on the body’s desires, passions, and conflicts they despise. They can also project vulnerability on others whom they treat with contempt. These patients often describe a superior part of the self that passively observes and looks down on another part of the self that is perceived to be in pain and need of help. Any attempt to understand, which inevitably leads to some experience of pain, is treated with great suspicion.

The analyst is trying to provide a psychological home in which different elements of the personality can be thought about. In the transference, the battles that occur between the parents and child in the home can be repeated, with the analyst experienced as a controlling figure who is against transition (e.g. “It’s my body, and I will have a mastectomy if I want one”). It should be acknowledged that the child’s wish to transition can, in part, be driven by a healthy desire to separate from the primary object and form their own identity. As the individual’s wish to transition is often mixed up with an over-involved relationship with the primary object, some rebellion and impulse to separate from these relationships are necessary and important. This situation may become a battle about whether the analyst is working unquestioningly towards the patient’s goal of transition or whether there is room to think with the analyst about what is going on.

As part of the transference, there are always ethical concerns regarding repetition in the therapy of past dynamics that were problematic for the patients. In his paper “On arrogance”, Bion (1959b) describes the oedipal myth in terms of the patient experiencing the curiosity of the analyst as arrogance, as the analyst wants to reveal the truth at all costs and without any consideration for how it leaves the patient feeling. He also describes the ethical dangers: “The very act of analysing the patient makes the analyst an accessory in precipitating regression and turning the analysis itself into a piece of acting out” (Steiner, 1993, pp. 50–51). Subtle enactments between analyst and patient are inevitable. If the analyst is open-minded and follows the patient’s response, these enactments can be picked up. Analysts are open to thinking about how the relationship influences them personally and can reflect upon and get hold of the interaction. Recognition of the enactment can deepen the understanding of how the patient operates. Another conflict that can be enacted in the transference is the claustro-agoraphobic dilemma that gender-dysphoric young people frequently seem to be caught in with their parents (Evans, 2021; Weiss, 2023). They often seem persecuted by the fact that they believe they are not the child their parents wished for. And they feel crushed by these phantasied expectations. They develop an idea that they will not be free to be themselves until they have distanced themselves from these persecutory expectations. It is like saying, “I know I’m a disappointment so I’m not even going to try.” However, they are often stuck in a bind as they worry that in killing their parent’s child, they will lose their parent’s love and support. This conflict is inevitably enacted in the transference, as the patient worries that the analyst will only sustain interest in them if they suppress their wish to transition. They may harbour a belief that the success of the therapy will be measured by whether they relinquish this wish.

A challenging experience in the countertransference complicates the therapeutic relationship. For instance, I often feel caught between the wish to remain in the positive transference, thus avoiding conflicts that could threaten the therapy, and the wish to address certain states of mind that bypass thought. The latter involves exploring underlying motives of defences and unconscious phantasies, which could make me the bad object and lead to a breakdown of the therapy. For those considering medical intervention, the therapy treads a tightrope between the wish to develop a therapeutic relationship, allowing the analyst and patient to explore different aspects of the personality and ways of relating, and bringing in some of the aggression directed towards the therapy through plans to transition. This can be difficult to manage, as some of the planned actions can leave the analyst feeling provoked by the irreversible nature of medical interventions.

The difficulties which can sometimes arise when the analyst tries to analyse rather than support the patient’s view have been put in the context of a “missing” third position, as noted by Britton:

I came to realise that efforts of mine to consult my analytic self were detected by such patients and experienced as a form of internal intercourse of mine, which corresponded to parental intercourse. This, they felt, threatened their existence. […] The possibility of communicating with a third object was unthinkable, so the third position I referred to was untenable. The third object in such cases could be my theories, links with colleagues or the residue of previous analytic experience.

Consequently, it seemed impossible to disentangle oneself sufficiently from the to-and-fro of the interaction to know what was going on. Any move towards objectivity could not be tolerated. The analyst and patient were to move along a single line and meet at a single point. There was to be no lateral movement. A sense of space could be achieved only by increasing the distance between us; a process patients find impossible to bear unless they initiate it. In such situations, I desperately needed a place in my mind to step sideways from which I could look at things. If I tried to force myself into such a position by asserting a description of the patient in my own terms, violence would always follow psychically, sometimes also physically. (2004, pp. 48–49)

Sometimes, the patient responds by retreating to a superior withdrawn state (as described earlier in this section), with the analyst trying to maintain sympathy while considering the fragility to be seen in the patient. Although “for or against” often refers to the support “for or against” the wish for medical intervention, it may also refer to the analyst being challenged to show that therapy has something to offer in place of the patient’s fantasy. Like hysterics demanding exclusive love, the patient can engage with the analyst while attacking and undermining the analyst’s relationship with others, including the internal relationship with psychoanalytic theory and practice. Patients in this state can saturate the analyst’s mind with actions designed to provoke reactions rather than thoughts, threatening the therapeutic setting and the analyst’s thinking capacity.

There is always the difficulty of finding space to think about meaning outside the dyad of the “for or against” transition, which comes into the therapy already at the start of treatment and of the transference–countertransference relationship. That is, the starting point for the therapy is the nature of the contract and the goal of the treatment. Who wants the treatment, and what for? Although everyone I describe in these cases is over eighteen years old and thus free to make their own decisions, many depend on their parents for support and approval. In addition, some individuals agree to see an analyst as part of an agreement with their parents, hoping to reassure them that the issue of medical transition has been thoroughly explored.

In this frequently occurring context, the question quickly arises as to whether the analyst is working for the parent who wants the patient to give up thoughts of transition or the patient who believes that transition is the solution to their difficulties. The patient will have questions about whether the treatment is genuinely for him or if the analyst is working on behalf of the parent(s) and their agenda. The issue of coercion thus needs to be addressed at an early stage. I do so by taking up the patient’s suspicions that I am pushing the parents’ agenda or otherwise trying to dissuade him from pursuing medical transition. More generally, the patient often watches to see if there is any evidence that the analyst wants to control or coerce the patient to fit with the analyst’s agenda. Patients sensitive to issues of coercion and control will look for a relationship with an object that can help them explore their minds without being provoked into a coercive or controlling stance. Again, experience has taught me that it is best to get these issues out in the open by acknowledging that I am concerned that the individual may be planning interventions with long-term, irreversible implications.

Any analysts working in this area need to establish a setting in which they are supported in withstanding the countertransferential forces towards unquestioning acceptance of the patients’ beliefs and desires on the one hand or over-controlling authoritarianism on the other. In my experience, pressure in the countertransference is increased by the patient’s tendency to project doubt or capacity for thought about losses into the analyst. This increases the likelihood of premature interpretations by the analyst to force sense into a threatening situation. The projection of doubts and confused states of mind can leave the patient deprived of the capacity for symbolic thought, and the pressure to provide active responses to the concrete nature of the patient’s communication can also interfere with the analyst’s capacity for creative or symbolic thought, particularly when the desired actions may have profound long-term implications for the patient’s body and sexual functioning.

To extricate themselves from the dynamic of concrete psychological action and reaction, analysts need to free themselves from feeling responsible for the patients’ actions. The analyst also needs to be aware that impulses to rescue the patients from their mental state, although well-intentioned, lead to a cohesive approach in the therapy, where the wish for cooperation and the sense of being in a cooperative relationship is adopted at the cost of avoiding exploration (which may lead to conflict and turbulence). Supervision is essential in working with these cases, as the supervisor outside the dyad of analyst and patient can pick up on any cohesive tendencies in the therapeutic approach. Supervision can help the analyst recover from the influence of the patient’s projections and feelings of powerlessness or guilt associated with the wish to protect. When analysts find that they are supported in their work, either with supervision or through support from colleagues, they can recover their capacity for symbolic thinking. This can deepen emotional contact with increased access to unconscious material over time. These developments can enable the analyst and patient to function more effectively as a therapeutic couple.

While analysts may quite understandably have reservations about the harmful effects of premature transition, they need to establish a position in which they are interested in understanding the patient’s point of view, even if this feels harmful. For example, female patients might believe that they cannot live life until they have removed any evidence of feminine sexuality. How does the analyst find room to explore the issue without falling into the trap of collusion on the one hand or coercion on the other?

Analysts need to try to establish a position to explore patients’ difficulties without colluding with thoughtless action or advocating for conformity with parental wishes. Analysts have the task of establishing a position in which they can empathise, understand, and be sympathetic with the patient’s position and point of view, as well as (if relevant) the parents’ concerns. Analysts are to do so while establishing and maintaining a setting where they can explore the meaning and unconscious motives behind symptoms and planned actions and maintain their capacity to think about the meaning of these states of mind. It’s helpful if analysts can find a setting in their mind in which, although they can empathise with all parties, they can continue to think for themselves.

A two-stage process can be used to try to get to this point. First, the analyst empathises with how the individual sees the world. As Britton noted:

The only way I found of finding a place to think that was helpful and not disruptive was to allow the evolution within myself of my own experience and to articulate this to myself, whilst communicating with the patients my understanding of their point of view. (2004, p. 48)

Understanding builds from the patient’s perception, with the analyst forming a well-developed picture of the individual’s views of themselves in relation to others. The need for the analyst to tolerate the patient’s view of the analyst and the therapeutic encounter is highlighted by Steiner (1994). The patient can perceive the analyst as being unhelpful, defensive, misunderstanding, arrogant, cruel, moralistic, or obsessed with pushing theories into the patient, irrespective of the pain it might cause. Having the analyst take in the perception of the object is required for patients who project very concretely. Steiner argues that insight might only be given back to the patient after his view of the analyst has been tolerated and taken in by the analyst. This can be considered as the first stage of the process. I have seen patients’ capacity for self-reflection increase when I started by concentrating on how they saw me, with my shortcomings, and how I tolerated being seen as a self-interested analyst trying to exercise my authority over them.

Once this understanding of the patients’ perception is established and tolerated by the analyst, it may be possible to interest the individual in the cost of their beliefs or other ways of seeing themselves and who they are. In the second stage of therapeutic work, the analyst has the task of separating from this identification and thinking about the patient as a separate person. The patient needs to hear the analyst’s thoughts about the former’s difficulties. This second stage introduces a third position that supplements the patient’s perspective. Sometimes, the therapeutic process goes back and forth between the two stages.

Problems can arise in both phases. In the first phase, there is a danger that the analyst can get stuck identifying with the patient’s point of view and avoiding the analyst’s own observations about what the patient communicates, leaving no room for objective assessment. I would notice myself, as mentioned earlier, being affected by the pressure I felt consciously and, in the countertransference, avoid being seen as the persecutory object trying to impose my ideals on the patient. The second stage can introduce ways of thinking that interfere with the patients’ view of themselves. As mentioned above, taking the third position of a third object can be experienced as persecutory, as “threatening their very existence” (Britton, 2004, p. 48). It also could develop a sadomasochistic flavour, repeating the relationship between the patient’s ego and superego, as some of my observations could be interpreted as deliberately shaming or hurtful.

Throughout therapy, the analyst needs to remind themself of the need to respect the patient’s defences. The patient’s rigid belief systems defend against fears of depressive guilt for remorselessly attacking the good object on the one hand and fragmentation on the other. The analyst’s function is to understand both the anxieties behind the defences, rather than confront the defences head-on, and to understand the role of the defensive structures, such as a psychic retreat, in protecting the individual from these underlying conflicts and anxieties.

Weiss described the challenges when emerging from a psychic retreat: “particularly when feelings of guilt have assumed a concrete and overwhelming quality, so that they cannot be worked through, but are turned backwards towards the self in the form of self-accusations and self-harm” (2020, p. 80). The Riviere Dilemma can occur, as Weiss (2020) described, as a situation in which the individual feels full of internal damaged figures that he fears he cannot repair. (“Love brings Sorrow and sorrow brings guilt: the intolerable tension mounts, there is no escape, one is utterly alone, there is no one to share or help” (Riviere, 1936, p. 313).) This poses a difficulty for therapy as

At the same time, they fear that every failure and every collapse will bring them closer to the threshold of madness so that inner reality might become real through the analyses. Thus, contact with an analyst who might expose some of these underlying difficulties can leave the individual feeling exposed and in danger of being overwhelmed by powerful feelings of guilt about the extent of the damage done in phantasy and literally. (Weiss, 2020, p. 84)

Forcing individuals to face reality can either lead to their rebelling against an intrusive process on the one hand, with an impasse or breakdown in the therapy, or subjecting themselves masochistically to a sort of moral tyranny on the other hand. Neither approach leads to ongoing psychological change and development. In addition, many children and young people turn to concrete medical intervention when any psychic equilibrium is challenged. I have found that psychotic states of mind erupt into and threaten therapy when the individual’s defences are endangered or overwhelmed.

Thus, although we believe the truth is a critical facet of any psychoanalytic therapy because we think it is an essential component of psychological development, a reckless search for the truth without compassion or sensitivity to the patient’s state of mind can disregard the need for individual protection from overexposure. The analyst needs to protect the patient from overexposure and ensure that the therapeutic process does not unfold too quickly or become intrusive.

Consequently, what I say to the patient differs from what I might think regarding my understanding of his presentation. One is sensitive to timing and what sorts of interventions the individual can manage and use at any given time. It would be helpful if clinicians could attune themselves to how the individual will likely hear the intervention. Even the most sensitive intervention can induce a modicum of shame and humiliation, pushing the individual away from emotional contact. Topics that may lead to embarrassment or shame should be addressed sensitively, with the individuals controlling what is discussed and when. I try to keep in mind the patients’ feeling of humiliation of having to put their difficulties into words, as they will often be attacked and mocked by their ego-destructive superego that perceives any weakness or problem.

Similarly, the interpretation of the aggression towards the self can open the possibility of exploring their fears of aggression and the inhibitions in their relationships and lives. I sometimes have drawn attention to how their minds worked, such as the dominance of the ego-destructive superego and how it is so full of hatred of the self. However, it is important to be aware that drawing attention to the extent of self-hatred can also produce feelings of shame and humiliation, leading to a negative therapeutic relationship. I also try to draw attention to the mind’s restrictive quality while understanding that analysis of self-hatred can raise anxieties about the damage done. In addition to respecting the role of defences in safeguarding individuals from overexposure, analysts have the task of pointing out the cost of these defences. I work to develop the therapy as a container that could think about an individual and their experience.

While the receptive nature of psychotherapy tends to mean that analysts should follow the patient’s material and timeline, we must also be curious about why some material is presented at any given time and what is absent in sessions. We need to be wary of forcing the agenda. Still, we also need to remember that we might be avoiding difficult areas of exploration and thought, which can significantly influence the patient’s actions. The avoidance may influence premature actions of foreclosed thought and exploration of a problematic conflictual area of mental functioning.

If a conflict between the self that wants to transition and the part that wants to escape from the psychic retreat is present, it needs to be fully explored. As we know from the research, many young people give up the idea of transition as a solution to their difficulties as time passes. For others, their thinking may gather momentum while their anxiety pushes them towards a need to act. This can produce a crisis, as part of the individual pushes towards concrete action while another part is full of doubts. As noted in the introduction, the part full of doubts can be projected onto parents and analysts, where it may be disparaged or dismissed as bigotry. Individuals can then feel free to push ahead, acting out their resentment towards the primary object they feel has betrayed them but protecting the primary object from aggressive attacks that they do not believe they can repair. Detransitioners often report feeling they knew they were pushing ahead with something they thought would provide a powerful solution while refusing to listen to any doubts in their minds. They wish they had been able to listen to these doubts before they underwent medical interventions.

The analyst needs to listen to the countertransference in picking up these unconscious communications and then find a way to interest the individual in missing aspects of their minds. On some occasions, patients may speak of a voice in their head casting doubt on their wish to transition or expressing a worry that they will not pass in their new gender. The analyst must listen to these communications, which the patient might ignore or dismiss. In practice, this is a painful oscillating process, with the patient moving towards emotional contact one minute and away from emotional contact the next. As discussed above, the analyst must also be aware that emerging from a psychic retreat is a frightening and threatening experience that cannot be rushed and requires patience and understanding from those involved.

The analyst must be curious about the nature of the individual’s difficulties, aligned with a capacity to demonstrate compassion and restraint. The process of separation and helping the individual develop a mind of his own comes about through noticing how the analyst and the individual behave. This ability to notice introduces the capacity for critical thought, and then the gap between the self and object allows room for symbolic thought. All of this can easily collapse when the individual feels too worried about his hostility, reprisal from the analyst, and guilt. However, if the individual can be supported through this difficult process, it leads to mourning, which might allow for development.

The threat of medical harm

Both the analyst and the patient may worry that they will present unmanageable challenges to the therapy, as the child or young adult often expresses the desire to start medical procedures, including puberty blockers, testosterone or oestrogen, and mastectomy or castration. Therapy aims to support an individual in making decisions; however, few analysts could remain unaffected by a patient’s plan to have a double mastectomy or take cross-sex hormones that might leave them infertile. The pressure of time due to the threat of medical transition, irreversible beyond a certain point, also puts pressure on the analyst and may interfere with the analyst’s equipoise. The analyst is likely to worry about short-term medical solutions with long-term harmful effects and that a rapid transition might be driven by a belief that concrete actions can solve psychological problems. A wish to protect the individual from possible self-harm that he might later regret or a desire to help the patient can be experienced as intrusive or controlling. For instance, as mentioned earlier, the individual can pressure the object (analyst) to provide unquestioning backing, which leads to a “for me or against me” atmosphere (Bell, 2020). This can leave analysts feeling that while they can identify with the patient’s subjective experience, there is no room for objective thought.

Moreover, this dynamic can rapidly turn into what Steiner describes (2022, pp. 50–53) as a vertical relationship driven by preoccupations with power and control. The threat of the patient instigating premature, irreversible medical interventions can put pressure on the analyst to become overactive to control the patient’s actions, and therapy can degenerate into a punishing relationship in which both parties act and react. One version of such a dynamic can revolve around the issue of reality. Patients often discuss their beliefs as concrete realities while treating external reality as something without a concrete physical existence. One has the impression that they live in the interior of their minds and feel affronted by their limited control over external reality. There can also be an attempt to treat external reality as if it were just an extension of the individual’s thoughts. The threat of precipitating medical interventions can push the analyst into a position where it is necessary to remind the patient of the realities and risks of the transition, for example, that the body is not just a product of our minds but also exists in physical reality beyond the mind’s control. Thus, the analyst might find themself voicing interpretations that traumatise the patient by forcing the individual to face reality. Or the analyst might realise, in hindsight, that an interpretation was used to control the patient’s actions.

Analysts must resist the temptation to play God, as if they know how patients should live their lives. Although this may be driven by a genuine wish to protect the patient, it often results in the patient shutting down or retreating into a dogmatic position of certainty. In addition, in pointing out the dangers of transition to the patient, the analyst may play the part of a punishing superego. In contrast, the patient assumes the role of a masochist or rebellious ego. As mentioned above, a power struggle can ensue where the patient’s internal conflict is re-enacted in the therapy.

While acting-out may be inevitable, I try to restore my equipoise whenever I fall into judgemental states of mind. I try to be an empathic observer and do my best to comment on the unconscious drivers of my actions. I try to maintain neutrality by establishing a position where I remain agnostic about whether the individual will transition in the long run. It helps that I cannot act as a gatekeeper for medical interventions. Although I am concerned about the risks of precipitate action, I remind myself that I am not responsible for treatment outcomes. This is an attempt to protect the analytic setting in which my primary responsibility is to listen to and understand the patient. However, I believe in considering the individual to help him make informed decisions about the future.

Given the fragile nature of the therapeutic relationship, the analyst may feel tempted to leave conflicts over medical transition outside the consulting room to foster the therapeutic alliance and to avoid a repetition of a sadomasochistic relationship between the mother and the child or the superego and ego in the transference. However, avoiding the issue can leave unconscious fantasies unexplored and in danger of erupting into the therapy at any time. Aggressive action towards the self, directed at the primary objects, can enter the therapy in dramatic ways. For example, patients may suddenly inform the analyst that they are about to commence cross-sex hormones without any discussion or time for reflection and thought. Similarly, they may explore the possibility of mastectomy. Adult female patients referred to the Portman Clinic had usually already had bilateral mastectomy before psychodynamic consultation (Anne Zachary, 2023, personal communication).

Mourning

Many who are trans-identified or have gender dysphoria have not completed the mourning associated with the developmental steps of separation and differentiation. The mourning process requires the individual to move from the internal grievance towards a concretely experienced failed ideal object and then towards a psychological separation between self and object: “Mourning the loss of omnipotent control of the object, and then mourning the loss of the object itself, is what leads to meaningful change” (Steiner, 1993, esp. chapter 4 and pp. 92–96). These steps are also relevant regarding engagement with the analyst as the individual softens their rather hard, often impenetrable, defence and allows the analyst to make more emotional contact.

Steiner (2023, personal communication) has described how preoccupation with grievances and wishes to exact revenge towards failed ideal objects can interfere with the mourning process and lead to stuck individuals. The concrete thinking of the melancholic can be a major obstacle. He describes how (as also discussed in Chapter Two) the individual may be haunted by reproachful figures in the internal world who demand concrete solutions to psychological problems and how one such solution is to pursue the idea that the lost ideal self and object can be restored rather than mourned and relinquished.

In the therapeutic relationship, the individual is offered the opportunity to explore the dynamics of internal grievances and fantasies of revenge that interfere with the mourning process. This exploration may include confronting the idea of revenge, where the individual symbolically attacks the external object. In therapy, individuals can express their disappointment with the analyst and the therapeutic process, whether for perceived or actual failings. When the individual addresses these feelings of failure with the analyst, it can lead to remorse, guilt, and ultimately, the relinquishment of old grievances—steps necessary for mourning. However, this process can be hindered by fears that the desire for revenge might inflict lasting damage on the object, burdening the individual with guilt for harming the failed ideal in external reality. This fear may cause the individual to retreat, collapsing wishes for revenge in external reality into familiar patterns of nursing grievances against the failed original object. Consequently, the patient may oscillate between harbouring internal grievances and attempting to express them through revenge fantasies, only to retreat again into resentment. At times, the individual may become preoccupied with feelings of betrayal directed towards the analyst. This fixation can impede the ability to let go of past preoccupations, inhibiting forward movement and mourning. Another potential obstacle arises when the individual’s unrestrained expression of aggression towards the analyst provokes fears of retaliation and guilt, leading him to terminate therapy abruptly.

For individuals with an overly close relationship to a maternal object and a lack of influence from a third party to facilitate separation, a specific pattern may emerge as therapy progresses. Such patients often seek a paternal figure who can provide the psychological space needed to develop a coherent sense of self. However, this exploratory process can be deeply painful. The internal object may feel so damaged that the individual either searches for or identifies with an idealised phallic figure rather than a more ordinary, symbolic representation of connection, such as the penis as a link (Birksted-Breen, 1996).

To protect themselves from vulnerability or to repair the damaged internal object, individuals may seek a powerful persona or idealised self to identify with. When the idealised object—or the idealised self— fails to provide the promised protection or necessary cure, intense resentment arises, fuelled by a sense of betrayal. This grievance may remain dormant for some time but often surfaces during disappointment. These unresolved grievances can impact the individual’s relationship with the primary object and create a significant block in therapy, ultimately obstructing the mourning process.

Progress in the therapy relies on the analyst’s ability to help individuals develop a mind of their own, including their own observations of the analyst and the analyst’s shortcomings. Using exploration and thinking to work through feelings of disappointment (with what the therapy can achieve and with perceived slights and misunderstandings) can help the individual’s process of separation and differentiation. This, in turn, allows a shift from concrete thinking associated with an undifferentiated relationship between self and object towards psychological separation. This development leaves room for symbolic thought: reparation can be made symbolically about future object relations while mourning the loss of the ideal object. This process can also assist the individual in leaving behind preoccupations with disappointments about the past and the present, instead becoming preoccupied with struggles involved in the future.

In the therapeutic relationship, the individual is offered the opportunity to explore the dynamics of internal grievances and fantasies of revenge that interfere with the mourning process. This exploration may include confronting the idea of revenge, where the individual symbolically attacks the external object. In therapy, individuals can express their disappointment with the analyst and the therapeutic process, whether for perceived or actual failings. When the individual addresses these feelings of failure with the analyst, it can lead to remorse, guilt, and ultimately, the relinquishment of old grievances—steps necessary for mourning.